Systemic lupus erythematosus, following prodromal idiopathic thrombocytopenic purpura, presenting with skin lesions resembling malignant atrophic papulosis.

Systemic lupus erythematosus (SLE) is an autoimmune disease. Its incidence in the UK is approximately 1 per 10 000. Cutaneous involvement, encompassing acute, subacute and chronic disease, occurs in over two-thirds of cases, and can often be the first clue to diagnosis. We describe a highly unusual case of SLE occurring after prodromal idiopathic thrombocytopenic purpura (ITP) and presenting with skin lesions more typical of malignant atrophic papulosis, a rare and often fatal vasculopathy. Such a combination of rare features emphasizes the potential for complexity in this multisystem disease.

Hair diagnoses and signs: the use of dermatoscopy.

BACKGROUND: Hair-shaft examination is diagnostically useful in a range of adult and paediatric conditions. OBJECTIVE: To evaluate the usefulness of dermatoscopy in hair-shaft microscopy. METHODS: Typical examples of selected conditions from an extensive collection of scalp hair were examined using a dermatoscope and a light microscope with paired cross-polarizing filters. Hair-shaft characteristics were photographed using a digital camera. RESULTS: Dermatoscopy was helpful in detecting tapered hairs, weathering, monilethrix, pediculosis capitis, peripilar casts, 'exclamation-mark' hairs of alopecia areata, bubble hair and pili torti. It was less helpful in pili annulati and unhelpful in detecting 'tiger-tail' banding in trichothiodystrophy. Light microscopy provided greater detail in almost all cases; it was necessary for detection of cuticle changes and added significant information in detecting characteristic features of trichothiodystrophy, pili annulati, bubble hair and pili torti. CONCLUSIONS: Dermatoscopy is most revealing in conditions resulting in gross changes in shaft outline and colour, where reflected light is valuable. It is unhelpful for detection of features within the shaft or at higher levels of resolution. When added to its ability to aid evaluation of scalp surface characteristics, dermatoscopy provides an excellent first-line method of assessment in clinics. In vivo it may aid screening and selection of hairs of greatest diagnostic yield for further assessment. In some instances, it may obviate the need for obtaining hair specimens and have implications for public health screening. Where detailed or cortical hair-shaft features need assessment, transmitted light microscopy remains the standard tool.

Bioabsorbable polymeric material coils for embolization of intracranial aneurysms: a preliminary experimental study.

OBJECT: A new embolic agent, bioabsorbable polymeric material (BPM), was incorporated into Guglielmi detachable coils (GDCs) to improve long-term anatomical results in the endovascular treatment of intracranial aneurysms. The authors investigated whether BPM-mounted GDCs (BPM/GDCs) accelerated the histopathological transformation of unorganized blood clot into fibrous connective tissue in experimental aneurysms created in swine. METHODS: Twenty-four experimental aneurysms were created in 12 swine. In each animal, one aneurysm was embolized using BPM/GDCs and the other aneurysm was embolized using standard GDCs. Comparative angiographic and histopathological data were analyzed at 2 weeks and 3 months postembolization. At 14 days postembolization, angiograms revealed evidence of neck neointima in six of eight aneurysms treated with BPM/GDCs compared with zero of eight aneurysms treated with standard GDCs (p < 0.05). At 3 months postembolization, angiograms demonstrated that four of four aneurysms treated with BPM/GDC were smaller and had neck neointima compared with zero of four aneurysms treated with standard GDCs (p = 0.05). At 14 days, histological analysis of aneurysm healing favored BPM/GDC treatment (all p < 0.05): the grade of cellular reaction around the coils was 3 +/- 0.9 (mean +/- standard deviation) for aneurysms treated using BPM/GDCs compared with 1.6 +/- 0.7 for aneurysms treated using GDCs alone; the percentage of unorganized thrombus was 16 +/- 12% compared with 37 +/- 15%, and the neck neointima thickness was 0.65 +/- 0.26 mm compared with 0.24 +/- 0.21 mm, respectively. At 3 months postembolization, only neck neointima thickness was significantly different (p < 0.05): 0.73 +/- 0.37 mm in aneurysms filled with BPM/GDCs compared with 0.16 +/- 0.14 mm in aneurysms filled with standard GDCs. CONCLUSIONS: In experimental aneurysms in swine, BPM/GDCs accelerated aneurysm fibrosis and intensified neck neointima formation without causing parent artery stenosis or thrombosis. The use of BPM/GDCs may improve long-term anatomical outcomes by decreasing aneurysm recanalization due to stronger in situ anchoring of coils by organized fibrous tissue. The retraction of this scar tissue may also decrease the size of aneurysms and clinical manifestations of mass effect observed in large or giant aneurysms.

Evaluation of the single-incision arthroscopic technique for anterior cruciate ligament replacement. A study of tibial tunnel placement, intraoperative graft tension, and stability.

The tension in an anterior cruciate ligament graft may not be normal when the femoral tunnel is placed using the single-incision arthroscopic technique because the femoral tunnel is drilled through the tibial tunnel. We hypothesized that the in vivo tensile behavior of the double-looped semitendinosus and gracilis tendon graft can be normal or abnormal compared with the native anterior cruciate ligament, that the placement and angle of the tibial tunnel can predict the tensile behavior of the graft, that the graft with abnormal tensile behavior is associated with a nonanatomically placed tibial tunnel, and that the tensile behavior of the graft determines the stability of the reconstructed knee at 1 year. Total tension in the graft and knee flexion angle were measured in 14 subjects as the knee was flexed from 0 degree to 90 degrees. A graft force greater than 40 N at 80 degrees of flexion was considered abnormal. One year after surgery, the angle and position of the tibial tunnel were determined from roentgenograms, and knee stability was measured with a KT-1000 arthrometer. The criteria for anatomic tibial tunnel placement in the sagittal and coronal planes were derived from magnetic resonance images of uninjured knees. The tensile graft behavior was either normal (4 of 14) or abnormal (10 of 14) with the single-incision arthroscopic technique. The angle of the tibial tunnel in the coronal plane was predictive of abnormal tensile behavior. Abnormal tensile behavior occurred in anatomically placed tibial tunnels and was compatible with a stable and functional reconstructed knee at 1 year.

Can an isometer predict the tensile behavior of a double-looped hamstring graft during anterior cruciate ligament reconstruction?

An isometer, a highly compliant spring-scale device for measuring suture displacement, has been used intraoperatively by surgeons to select the optimal placement of the femoral tunnel for an anterior cruciate ligament graft. The isometer measures the displacement of a suture centered in a tibial tunnel and attached to an intraarticular location on the femur before the femoral tunnel is drilled. Because the placement of the femoral tunnel strongly impacts the tensile behavior of an anterior cruciate ligament graft and because surgeons have used the amount of suture displacement to guide the placement of the femoral tunnel, the objective of this study was to determine the ability of an isometer to predict graft tension. In 14 patients undergoing reconstructive surgery of the anterior cruciate ligament, an isometer was used to measure suture displacement during passive knee motion for a provisional femoral tunnel location. An electrogoniometer recorded the flexion angle of the knee. The femoral tunnel was drilled. A double-looped semitendinosus and gracilis autograft was inserted around a post in the femoral tunnel, and the tension in the four limbs of the graft exiting the tibial tunnel was measured during passive knee motion. Graft-tension versus knee-flexion-angle curves revealed that each knee exhibited one of two distinct curve shapes: L-shaped, characterized by the maximum tension occurring at full extension and a nearly flat profile from 35 to 90 degrees of flexion, or U-shaped, with elevated tensions at 80-90 degrees of flexion (p < 0.001) reaching at least half of the tension in full extension. Because the shapes of the suture-displacement versus flexion-angle curves were more consistently L-shaped, the intraoperative measurement of suture displacement was not a useful predictor of either the increase in tension in the graft with flexion or the maximum tension in the graft.

In vivo tensile behavior of a four-bundle hamstring graft as a replacement for the anterior cruciate ligament.

The purpose of this study was to measure the in vivo tensile behavior of a double-looped semitendinosus and gracilis graft used to reconstruct a torn anterior cruciate ligament in the human knee. In 14 subjects, intraoperative tension was measured for each of the four graft bundles during passive motion from 0 to 90 degrees of flexion. Two hypotheses were tested: (a) the peak tension carried by each of the four bundles was equal during passive motion, and (b) the mechanics of the bundles mimicked the functional bands of the native anterior cruciate ligament. The total tension was also calculated and used to determine strength requirements for fixation devices. The peak tensions of the four bundles during passive motion were not equal; however, enough tension was present in each bundle that load-sharing occurred between bundles. The pattern of tension between the anterior and posterior bundles mimicked the reciprocating load-sharing behavior of the functional bands of the native anterior cruciate ligament. Reciprocal tensile behavior was consistently achieved with the use of a single femoral tunnel centered on the most isometric line without the need for two separate femoral sockets. The maximum total tension was 296 N; this was nearly equal to the strength of one commonly used fixation device.

Studies of the pirouette mutation. 2. A detrimental phenotypic interaction with naked neck.

During a study to determine if any genetic linkage existed between the chicken mutations pirouette and naked neck, it was found that when both traits are expressed simultaneously in an individual, an "automutilation" condition can be created in some cases. The tremulous head movements of naked neck-pirouette chicks cause scraping of the skin on the neck against the egg shell during hatching, resulting in lacerations of the neck in varying degrees. Because of this potential for injury, it is suggested that matings between carriers of tremulous neurological disorders and carriers of mutations that result in lack of down cover be avoided whenever possible.

Studies of the pirouette mutation. 1. Lack of linkage association with marked regions of chromosomes 1 and 2.

The pirouette mutation was tested for possible genetic linkage with naked neck, tardy feathering, the MN t(Z;1) chromosome rearrangement, all assigned to distinctly different regions of Chromosome 1, and the OH inv(2) chromosome rearrangement and shankless (associated with the OH inv(2) rearrangement). No linkage associations were found in any of these tests. This eliminates specific regions of Chromosomes 1 and 2 as possible locations for the pirouette mutation.

Papillary carcinoma of the thyroid gland seen as lateral neck cyst.

The clinical, roentgenographic, histologic, and cytologic features of four cases of papillary carcinoma of the thyroid gland seen as lateral neck cysts are discussed. Carcinoma of the thyroid gland characteristically is a solid tumor and appears as a firm, painless, and otherwise asymptomatic mass in the anterior paramedial part of the neck. A nontender fluctuant lateral neck mass commonly implies a benign lesion. The diagnostic procedures used (namely, fine-needle aspiration and ultrasound and thyroid scans) may belie the nature of the lateral neck lesion. Examination of the tissue is necessary to confirm the diagnosis.